Coroner's Finding: ABBOTT Raymond

CORONERS ACT, 2003 SOUTH AUSTRALIA FINDING OF INQUEST An Inquest taken on behalf of our Sovereign Lady the Queen at Adelaide in the State of South Australia, on the 16th day of December 2016 and the 30th day of May 2017, by the Coroner’s Court of the said State, constituted of Mark Frederick Johns, State Coroner, into the death of Raymond Abbott.

The said Court finds that Raymond Abbott aged 70 years, late of the Semaphore Residential Care Centre, 122 Esplanade, Semaphore, South Australia died at Semaphore, South Australia on the 26th day of March 2015 as a result of chronic obstructive lung disease with emphysema on a background of advanced vascular dementia. The said Court finds that the circumstances of his death were as follows:

1. Introduction and cause of death 1.1. Mr Raymond Abbott was 70 years of age when he died on 26 March 2015 at the Semaphore Residential Care Centre in Semaphore. A pathology review was conducted by Dr Iain McIntyre from Forensic Science South Australia on 31 March 2015. Having regard to Dr McIntyre’s report, I find the cause of death to be chronic obstructive lung disease with emphysema on a background of advanced vascular dementia.

2. Reason for Inquest 2.1. On 15 March 2012 the Guardianship Board granted guardianship and administration orders to the Public Advocate and Public Trustee respectively. The Public Advocate was appointed guardian in relation to medical, accommodation and lifestyle decisions.

The Public Trustee were appointed as administrators and were to act in relation to all financial matters.

2.2. On 12 February 2013 the Guardianship Board made additional including provisions enabling the Public Advocate to stipulate where Mr Abbott had to be and reside.

2.3. The orders were sought by Mr Abbott's treating doctors at Glenside Hospital where he was a patient at that time. It was felt that Mr Abbott had been making poor financial, lifestyle and self-care choices. His health and safety were considered seriously at risk.

2.4. In law this meant that Mr Abbott’s death was a death in custody within the meaning of that expression in the Coroner Act 2003 and this Inquest was held as required by section 21(1)(a) of that Act.

3. Background and the events leading to Mr Abbott’s death 3.1. Mr Abbott moved into the Semaphore Residential Care Centre on 26 March 2013 and remained at this location until his death. He rarely engaged with other residents and proved difficult for staff to manage due to his verbal and physical aggression towards them.

3.2. Mr Abbott suffered from chronic obstructive airways disease, an opiate addiction, alcohol abuse, chronic heart disease, recurrent episodes of pneumonia and dementia with a feature of antisocial behaviour.

3.3. On 8 October 2014 Mr Abbott suffered a fall and was transferred to hospital. He underwent a chest X-ray and CT scans, but no fractures related to the fall were found.

The tests did however detect excessive degenerative changes to Mr Abbott's lungs in line with his former diagnosis of chronic obstructive airways disease.

3.4. On 10 March 2015 Mr Abbott was admitted to the Queen Elizabeth Hospital with shortness of breath and chest pain. He was assessed and tests were undertaken which detected a large left spontaneous pneumothorax. A chest drain was inserted. Mr Abbott pulled the chest drain out twice and so a pneumostat lung drain was placed in his left side.

3.5. On 23 March 2015 Mr Abbott had chest X-rays taken at the hospital. They showed that the left pneumothorax had increased in volume and there was persistent subcutaneous emphysema over the left hemothorax.

3.6. On 25 March 2015 it was clear that his condition was declining. He was returned to the Semaphore Residential Care Centre where his general practitioner instituted palliative care.

3.7. Mr Abbott remained pale, appeared weak and drawn and was confused and disorientated. He was not swallowing well and his diet was changed. Mr Abbott was incontinent, unable to walk, could not weight bear and was on continuous oxygen therapy for comfort. Mr Abbott was placed on a regime of four-hourly midazolam and endone and at approximately 12pm on 26 March 2015 the general practitioner reviewed his dose and increased the frequency to two-hourly given his condition and the imminence of his death.

3.8. Mr Abbott was peaceful and sleeping after the increase in medication. He died at approximately 2:10pm on 26 March 2015 in the presence of a carer who remained with him.

4. Conclusion 4.1. I find Mr Abbott’s detention was lawful and had no bearing on his death.

5. Recommendations 5.1. I have no recommendations to make in this matter.

Key Words: Death in Custody; Section 32 Powers In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 30th day of May, 2017.

State Coroner Inquest Number 66/2016 (0509/2015)